C09996199 / invoice 10000

eye gone all gunky again



Verified: YES

HISTORY
Presenting for: Cole , a young dog, presented for discharge from the left eye that recurred after previous treatment.
Historical Conditions: Previous episode of conjunctivitis approximately 2 weeks ago, initially affecting the left eye then spreading to both eyes. Treated with topical antibiotic ointment for one week with excellent response. Complete resolution occurred almost immediately after treatment commenced. Current episode began 2 days ago and is affecting the same left eye initially.
Behavioural: Very sweet and great temperament. Readily accepts treats during examination.
Current Meds: No current medications. Previous topical antibiotic ointment was used completely and discarded as instructed.

EXAM
Eyes: Left eye showing conjunctivitis with discharge. No structural abnormalities noted on examination. No ulceration present on fluorescein stain. Nasolacrimal duct patent as evidenced by fluorescein stain drainage through nostrils.
Diagnostics: Fluorescein stain performed on both  eyes - negative for corneal ulceration, 

ASSESSMENT
Conjunctivitis - likely allergic or irritant-induced given young age and tendency to investigate environment with face, though bacterial secondary infection possible.

PLAN
New Meds/Tx:
- amacin ointment  BID for 7 days
Additional Discussion:
- If episodes continue to recur, consider addressing as allergic condition with environmental or food allergy investigation and systemic allergy medications rather than repeated topical treatments

Sore gunky eye

Verified: NO

HISTORY
Presenting for: Cole, a recently acquired dog (owned for approximately 1–2 weeks), presented for a 3–4 day history of bilateral ocular discharge, initially affecting the left eye only, described as yellow-green in character with notable crusting/matting in the mornings.
Diet: Eating and drinking normally per owner.
Drinking/Urination: No changes reported.

EXAM
Behavioural: Well-behaved and stood calmly throughout examination.
Eyes: Bilateral yellow-green ocular discharge noted, worse in the left eye and more pronounced in the mornings. Conjunctivae not overtly inflamed; no scleral redness noted. No corneal ulceration detected on fluorescein staining.
Diagnostics:

- Schirmer Tear Test (STT): Both eyes normal (>15 mm/min); tear production considered adequate at time of testing.
- Fluorescein stain: Bilateral - negative for corneal ulceration in both eyes.

ASSESSMENT
Bilateral mucopurulent ocular discharge - DDx: conjunctivitis vs other.

PLAN
Amacin BID 5 days

Additional Discussion:
- Recheck recommended if no improvement within 7 days or if condition worsens.

Client Comms:
- Advised not to store or reuse the ophthalmic ointment after this course --> if ocular signs recur in future, patient must be re-examined prior to any further treatment given risk of steroid use in the presence of an undiagnosed ulcer.
- Return if no improvement within 7 days or sooner if signs worsen.